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H H S Department of Health and Human Services
Health Resources and Services Administration
Maternal and Child Health

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EPSDT Overview

Medical Necessity under EPSDT  

In a report prepared for the federal Health Care Financing Administration (HCFA, now known as Center for Medicare and Medicaid Services – CMS), Rosenbaum and Sonosky described the EPSDT medical necessity standard as follows:

"While there is no federal definition of preventive medical necessity, federal amount, duration and scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit can be reasonably achieved.... Since the purpose of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of coverage is necessarily broad... the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities."